A National Survey of End-of-life Care for Critically Ill Patients

TLDR

End‑of‑life care in ICUs shows wide variation, with fewer CPR attempts and more frequent withdrawal of life support compared to a decade ago. To determine the frequency of withdrawal of life support, we surveyed all American postgraduate training programs with significant critical‑care exposure. The survey asked each program to prospectively classify deceased patients into one of five mutually exclusive categories. Among 6,303 deaths reported from 131 ICUs, 38 % had life support withdrawn, 10 % withheld, 23 % received full ICU care with failed CPR, and 22 % received full ICU care without CPR, with wide variation across units but no association with ICU or hospital characteristics, indicating that withdrawal of life support is the predominant practice.

Abstract

In some intensive care units (ICUs), fewer patients who die now undergo attempts at cardiopulmonary resuscitation (CPR), and many more have life support actively withdrawn prior to death than did a decade ago. To determine the frequency of withdrawal of life support, we contacted every American postgraduate training program with significant clinical exposure to critical care medicine, asking them prospectively to classify patients who died into one of five mutually exclusive categories. We received data from 131 ICUs at 110 institutions in 38 states. There were 6,303 deaths, of which 393 patients were brain dead. Of the remaining 5,910 patients who died, 1,544 (23%) received full ICU care including failed cardiopulmonary resuscitation (CPR); 1,430 (22%) received full ICU care without CPR; 797 (10%) had life support withheld; and 2,139 (38%) had life support withdrawn. There was wide variation in practice among ICUs, with ranges of 4 to 79%, 0 to 83%, 0 to 67%, and 0 to 79% in these four categories, respectively. Variation was not related to ICU type, hospital type, number of admissions, or ICU mortality. We conclude that limitation of life support prior to death is the predominant practice in American ICUs associated with critical care training programs. There is wide variation in end-of-life care, and efforts are needed to understand practice patterns and to establish standards of care for patients dying in ICUs.